Provider Demographics
NPI:1235512260
Name:GOLDEN, TRACY
Entity Type:Individual
Prefix:
First Name:TRACY
Middle Name:
Last Name:GOLDEN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1583 S 1600 E
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84105-2829
Mailing Address - Country:US
Mailing Address - Phone:801-597-5386
Mailing Address - Fax:
Practice Address - Street 1:3970 S 700 E
Practice Address - Street 2:#17
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84107-2191
Practice Address - Country:US
Practice Address - Phone:801-639-9544
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-07-08
Last Update Date:2015-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT364944-6004101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health